(1) Changes to an individual patient's medication are emailed to carers and a new prescription (MAR) chart is issued but there is no procedure in place to ensure that individual carers have read and specifically acknowledged any medication changes (2) It is unclear what additional measures or cross-checking have been introduced to prevent a subsequent carer; who is attending a patient; from inheriting a medication error from an earlier attendance and repeating that error: (3) There does not appear to be any process for individual carers to sign to acknowledge having read and implemented patient's care plan in the patient's log book: (4) There does not appear to be a system for recording on a patient's records specific medication instructions or changes to medication which might have been given or taken by mobile phone (5) There does not appear to be any electronic system or record to enable carers to access a patient's medication history, the records at the patient's home being only paper records_ (6) There is a specific concern in Mrs Planner's case about the robustness of the subsequent Carewatch investigation and any learning that would arise to prevent incidents in the future, since Carewatch had not procured the original paper patient records from Mrs Planner's home address at any stage during their investigations or prior to the inquest hearing: This may have compromised the ability to assess the accuracy of records to which the individual carers had access, any impact that may have had upon the medication error; or any learning to arise in the context of record keeping and application of medication care plan requirements by carers